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Dr. Cushing diagnosed it as contact dermatitis from chemicals in the operating room.

He then got in touch with an acquaintance of his in Akron, Ohio, a Mr. Goodrich, and asked if he could make some rubber gloves for his nurse. Soon the gloves arrived and the dermatitis disappeared.

So, in one brief interview, I had intimate brushes with the lives of four of the most successful men and one of the nicest ladies who lived in the 19th and 20th centuries.

The Joneses also related several other interesting anecdotes during that interview, but they do not pertain to surgical gloves. It was a very special event in my career.

Don E. Cloys, M.D.
Housestaff '67-68
Richmond, Ky.

Generally speaking
I was fascinated by the Spring 2005 "Grand Rounds" essay by Jonathan Ross, M.D., one of my mentors from DMS.

I also worked during my DMS years with Dale Gephardt, M.D., an internist in Windsor, Vt. Dale was a true generalist as defined in the essay. He provided continuous, comprehensive, personalized care. As we drove through Windsor on our lunch break, he could tell me stories about the people we saw in town, his patients. He knew them that well!

I envisioned myself working like Dale. I did my residency in primary care at the University of California at San Francisco because residents there spend 50% of their time with outpatients (I now spend more than 95% of my time with outpatients).

I opened a solo practice in San Luis Obispo, Calif., in 1998. My wife grew up here and we wanted to move here. The two group practices in town weren't hiring then, but luckily my father- in-law, Frank Collie, M.D., has been a Dale Gephardt in San Luis Obispo for over 30 years. He had room in his building, so we decided to share some employees and it has worked.

Like Gephardt and Collie, I strive to be an internist providing continuous, comprehensive, personalized care. I learn

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more about how to do that every year. What do I hear from my patients? They left their last physician because they never saw her or him. They could see only the nurse practitioner or physician assistant. Rarely was it the same person twice. They left a big group practice because they could never get hold of their physician on a "crazy" phone system. They want me to know who they are, to know a bit about their life. They frequently come to me after seeing a specialist because "you're my doctor and I'm not doing anything unless you agree." They (usually!) value my opinion. They trust me to provide palliative care during terminal illnesses.

I spend a fair amount of time on unreimbursed work: reviewing studies ordered by specialists or calling specialists to coordinate my patients' care. I do this because they are "my" patients. I am their advocate, someone armed with medical knowledge and knowledge of the medical system. I do this because they have trusted me with their care and I feel responsible for helping them. I dictate a list of medications for my geriatric patients, because I realize they are more likely to foul it up without a list. I make house calls.

I feel the care I provide could be better. I feel like a little island at times and wonder how other solo practitioners do it. Is the small-office care I provide better or worse then the care in a big system like Kaiser

or the VA? Do automated triage, computerized reminders, tracking of outcomes, or use of a limited formulary help patients more than I do? If I tried to track my own outcomes, would it produce useful information? Do nurse practitioners or physician assistants (I don't use either) provide the same kind of care I do? Do they save money or cost more for our health-care system (i.e., order more unnecessary tests) than I do?

Why don't more physicians want to do what I do? I don't think the lifestyle demands of providing continuous, comprehensive, personalized care have to be as big a barrier as many medical students perceive. I work pretty darn hard (though not the crazy hours of some specialists), and I make a respectable salary (though nowhere near what many specialists make). But I feel lucky to be doing something I enjoy. I am fortunate to have 10 other internists in my call group. What makes my life as an internist crazy is that my income is directly tied to how many patients I see. To earn my respectable salary, I have to see more patients than I'd like on many days. Better reimbursement for what I do would help draw more medical students to generalist care. So, too, would changing the mindset whereby generalist medicine is referred to by specialists as a "dumping ground."

Yet how to demonstrate, with research, the value of what an internist can do is incomprehensible to me. How to measure if patients prefer generalist medical care is equally unclear.

So that's the view, from my non-academic generalist shoes, on the interesting questions Jon Ross raised in his essay.

Stephen A. Hilty, M.D.
DMS '95
San Luis Obispo, Calif.

Can those be Kandahars?
The Summer issue of Dartmouth Medicine was another home run—from the Editor's Note, spiced with references from Oprah to Dumas, and the jazzy listing of the issue's contents, all the way to the end.

The feature about Susan McLane really pushed my nostalgia button. She and her twin sister were a fixture on the campus during my years at Dartmouth. And her husband-to-be, Malcolm McLane, DC '46, was just a few years behind me. I got a

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